Surgical tools left in five patients

UW surgeons take precautions to ensure it doesn't happen again

University of Washington surgeons have left five surgical instruments in patients during the past five years, including two13-inch-long retractors, the medical center said yesterday.

The most recent event occurred during a "complex abdominal surgery" for cancer in September and prompted immediate changes in the hospital's operating room policies.

"A malleable retractor used in closing the incision was mistakenly left in her body," said UW medical director Dr. Eric Larson. "We removed the object in October. We have accepted responsibility for this error and apologized to the patient."

The most recent case involved the same size instrument as one reported earlier this week involving Don Church, a Seattle pest-control technician. In June last year, UW surgeons removed a 13-pound cancerous tumor from Church's stomach, but left behind a 13-inch retractor in a case that made headlines as far away as London. Two weeks ago, Church received a settlement of about $100,000 from the UW.

"The Church case, it surprised us," Larson said. "When it happened again was when we realized this is a real risk." The incidents involved different surgeons.

After Church's case was discovered, the hospital began counting all retractors used in surgeries. In abdominal surgery, retractors, which look like large metal tongue depressors, are used to press intestines and other organs down while surgeons close the incision. They are typically removed through a tiny opening just before the patient is completely sewn up.

The other instruments left behind included a cardiothoracic retractor in February last year, a cardiac retractor in November 1997, and a clamp in March of 1997. The retractors used in heart surgery range from 6 to 10 inches long. The type of clamp left behind ranges between 6 and 12 inches long.

After the most recent case, the hospital began counting all instruments, large and small, used in "large-cavity" cases involving the chest, stomach and pelvis. Such cases use an average of between 250 to 300 instruments. Longer surgeries may use more than 600.

The new counting rules will require additional staff in the operating room, said Kathleen Sellick, executive director of the medical center, who also said she would dedicate additional resources to review all operating-room counting practices to see whether any other procedures would increase patient safety.

The UW performs about 12,000 surgeries a year, and metal instruments are left in less than one out of every 10,000 cases, Larson said. "But we are aiming for zero defects."

Nevertheless, patients anxious about their safety have been calling doctors at UW all week, said Dr. Carlos Pellegrini, chairman of the department of surgery, adding he personally had to reassure many of them.

Surgeons have always counted small instruments, including needles and sponges, but not large instruments, Pellegrini said. The additional counting carries some risk since it keeps the patient in the operating room under anesthesia longer.

As a backup, surgeons sometimes request post-operative X-rays to check for missing instruments. In two of the cases revealed by UW yesterday, the instruments were found by X-ray and removed before the patients were discharged.

All the instruments were later removed, and none of the patients suffered lasting damage, according to the medical center. The biggest risk of leaving an instrument in the body is infection.

"This particular incident has everybody's attention," said Dr. Rayburn Lewis, Providence medical director. "We're in the process of standardizing how and what is counted as well as reviewing our processes.

"This was an absolutely unfortunate incident, but one all hospitals set up safeguards to help prevent. Obviously this one slipped through the cracks."